The Missing Link: Public Health

Is not my health in my own hands? That is what we have been taught from childhood. Health is maintained by living right, avoiding ind­iscretion or excesses, keeping in balance the life forces within.  Keep body and mind clean and you will keep diseases at bay. These arguments are quite familiar to us. In truth they are spurious, and need to be revised.

True, there are a few diseases of ‘self-harm’—from substance addictions and promiscuous sex, for example, but they are not what we are discussing here. If I fall ill with tuberculosis, typhoid, or any of the innumerable infectious diseases widely prevalent in India, am I to blame myself? They were controlled in many countries early in the twentieth century. Why are they yet uncontrolled in India? Does not the government have some role in my illness? This is a critically important question.

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When we suffer with sickness, we need help—cure, or at least care. Treatments for diseases (for our purpose, ‘therapeutics’) have evolved in all cultures. If we keep shamanism and the like aside, physical remedies were practised from ancient times, using plants and minerals, and most evolved among them are the Indian and Chinese systems. Both have elaborate theories of disease-causes and cures. Treating the sick is the noblest among services rendered to fellow humans, and you can see these traditions being formed by that ethos.

In the eighteenth century, a new system called ‘homoeopathy’ was created in Germany—it sprang from the theory that ‘like cures like’, and engendered remedies based on that. From sixteenth century onwards, the European medical system had been growing in another direction too, imbibing scientific methods of verifiable dia­gnosis and therapeutics, using antidotes against disease-causes, and this eventually got the nickname ‘allopathy’. Actually, a more precise name for it would be ‘Scientific Medicine’. This system has now become universal, replacing traditional systems in most cultures.

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Scientific Medicine was brought to China and India by the British in the early twentieth century but was slow to be adopted, mainly bec­ause of the popularity of pre-existing systems that are still widely practised. In China, it grew fast—even producing a Nobel Prize-winner in Medicine in 2015. India has not quite overcome the over-sensitivity of valuing our own traditional system versus this new, imported system. The therapeutics within Scientific Medicine notably includes highly sophisticated surgical interventions. In that light, a degree of self-awareness about its own comparative lack can be ascribed to tradition. For instance, the government has the idea that if surgery is taught to traditional medical practitioners, the system will look like Scientific Medicine. This actually highlights the ambiguous attitude of the State on health management in important ways, with adverse effects on people’s health and lives. We shall see why.

Two fundamentals make Scientific Medicine unique—science and political ideology.  The theme of this paper is the latter, as elaborated below.

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First, about the science in Scientific Medicine: all other systems have theories about disease-causes which have to be believed without questioning, and hence qualify as dogmas. All dogma-based systems are ‘traditional medicines’. In Scientific Medicine, every element in causality, diagnosis and therapeutics can be questioned and researched and revised, further refining knowledge and improving practice.

The application of science had unforeseen rep­ercussions that made medicine more than social service. Discovering microbial causation of disease led to searching for the sources of microbes and their transmission pathways. Cholera is water-borne, malaria mosquito-borne, syphilis sexually transmitted, and all are preventable if those pathways are systematically targeted and made safe.  Thus Scientific Medicine bridged the barriers of soc­iology, environmental ecology and therapeutics. People’s living conditions, sanitation, hygiene, occupation and the nature of their soc­ial interactions had immense influence on the transmission of disease-causing microbes. Thus emerged insights into the ‘social determinants’ of diseases. The ecology of microbes and their vectors were also bound up with people’s interactions with the environment—and that clarified the ‘environmental determinants’ of diseases. Managing the environment controlled such diseases. In a sea of diseases, no man or woman is an island.

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Now, if governments are responsible for crime prevention, law, order, economic justice and fairness, solving disputes over contracts and ownership of properties—all social affairs—what should be done when social and environmental determinants led to an unfair distribution of diseases? Only the government has jurisdiction over people at large and the environment—so, my protection from infectious diseases is in the hands of the government.

Naturally, then, mitigation of disease is the government’s responsibility—it alone has the power to control the determinants of citizens’ health. Thus it was that, in European democracies, Scientific Medicine became one more governance agenda of the State. Traditional systems that did not recognise the social determinants of diseases had no compelling reason to become part of the governance agenda and remain in the social service domain. India is stuck in the Trisanku—we love the therapeutics of Scientific Medicine, but pay scant attention to its urgent call for mitigating disease determinants.

To highlight the sociological elements of Scientific Medicine, the term ‘social medicine’ was coined in Europe for the management of health, particularly by disease prevention through the mitigation of disease determinants. Social medicine was no longer purely ‘medicine’ but was more essential for health; hence it was renamed ‘public health’—thus separating it from therapeutics proper. In 1848, England passed the Public Health Act in parliament, enabling and ensuring the government’s responsibility to prevent preventable diseases and thus promote health. Law made the government accountable for citizens’ health and for controlling infectious diseases.

Now, if the State is responsible for citizens’ health, both public health and disease-care have to be a core part of the administrative functions of the State.  There is no ambiguity for using public funds for public health. What about expenses for disease-care, nicknamed ‘healthcare’? European political thinkers had two views, one demanding that all healthcare be managed and funded by the State—exemplified by the British National Health Service. The second allowed private sector healthcare, already existing as social service, only stipulating that expenses were to be covered by State. Different forms of insurance schemes were des­igned for funding all healthcare. All European democracies follow this principle.

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In medical curriculum, we are taught the history of medicine—so all doctors have learned all these. Then why are they not advocating for public health and universal healthcare? Doctors and their professional associations are concerned with healthcare, not the political philosophy on health management and the role of public health, or on healthcare financing.

Our government avoids the establishment of public health for two reasons. One: the cultural understanding of health/disease as individual responsibility and the ignorance about the social determinants of diseases absolve the government from guilt for not establishing public health.  Second: if public health is not established, the budget on health can remain very low.

If we did establish public health, India will req­uire a whole department with a network of institutions; trained personnel; cadre structure and career pathways; experts in public health and its foundation science of epidemiology and biostatistics; public health officers in all 718 districts; supervisory officers in all States and Union Territories; a network of public health laboratories with cutting-edge technologies. These will require funds, and my guess is that about 2-3% of the gross national GDP may be required.

Instead of public health, we have bits and pieces to satisfy international norms: thus we have the National Centre for Disease Control; stand-alone or vertical programmes to control tuberculosis (TB), malaria, HIV/AIDS, leprosy, filariasis and kala azar. Each has dedicated staff; none can claim success commensurate with inp—uts. India has one of the world’s highest burdens of TB, control eluding us over the past fifty years and more. While Western democracies controlled TB through public health, to 200 cases. Without public health and universal healthcare, I have no hope of TB control or the control of any other diseases with strong social and environmental determinants.

We cannot create more vertical programmes against cholera, typhoid fever, scrub typhus, leptospirosis, rabies and so on—therefore there is no national policy to control them.

When the HIV pandemic hit India, we sorely missed public health infrastructure but created a dedicated project under the Ministry of Health and applied a unique, indigenous design and succeeded in controlling it. It is now one more vertical programme. The 2009 influenza pandemic killed many, but we have no count. Counting of disease cases, and deaths due to diseases, both validated with specific criteria, are the functions of a public health system the world over.

The Covid pandemic puts a spotlight on India’s missing public health. Healthcare depends on protocol-based diagnosis and therapeutics. Public health depends on real-time information on spatial and temporal disease events and deaths by diagnosis, collected through ‘public health surveillance’, for immediate action that can protect the public from further damage. If ten persons die with a particular infectious disease in ten hospitals, life is routine for healthcare. If that information reached public health, swift action will be undertaken to unravel the causative microbe, its source and transmission channel, and to cut all chains of transmission.

Similarly, the true causes of death documented on death certificates are not of much value for the healthcare system or the revenue department, but they are of precious value for public health. Every diagnosis must be sifted for significance in disease epidemiology, and that is the job of public health. The world has understood that we have no system in place to count all cases or deaths by diagnosis of Covid-19. We are accused of ‘under-reporting’—but the reality is that we do not have the necessary public health surveillance in place, for the simple reason that we do not have public health itself.

Looking back, when the Covid-19 pandemic reached India in the first quarter of 2020, the government was in a quandary about how to design and implement appropriate control measures—precisely because it lacked the public health infrastructure to do so effectively. So, the National Disaster Management Agency (NDMA) was assigned the lead role to face the fury of its onslaught. In the 1980s, the Indian Council of Medical Research (ICMR) had pioneered an innovative response when HIV/AIDS hit—by establishing a National Task Force. It carried out a blitzkrieg of public education, starting with schools and colleges, covering both the basic facts that everyone needed to know and the behaviour changes that people had to adopt to protect themselves. Together, it was called ‘social vaccine’. Its legacy is visible as the National AIDS Control Project and Red Ribbon Clubs in high schools and colleges. The NDMA did not have the expertise to develop a social vaccine against Covid-19 or to establish an early comprehensive biomedical action plan, including vaccine development. It had no institutional memory of the concept of social vaccine that could have helped effectively to flatten the epidemic curves of both the first and the second waves.

The most important lesson for our country from the pandemic is the critical need for public health, so that we can respond sensibly and effectively to epidemics and pandemics. And they are bound to come again. A department of public health alone can overarch all vertical disease control programmes that are currently functioning as silos. Instead of each silo collecting health information on a single disease, comprehensive public health surveillance can provide reliable data for monitoring the trajectories of control of all important infectious diseases. Public health can be assigned with accountability to control diseases.  Epidemiologists can understand the behaviour of disease-causing microbes and can plan and execute pre-emptive actions.

It’s simple. The health of the citizenry is the State’s responsibility in all modern democracies. This question is more political than medical: do we want to become modern or remain traditional?

(Views are personal.)